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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850038
Report Date: 10/06/2022
Date Signed: 10/06/2022 12:19:29 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2022 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20220616110908
FACILITY NAME:ARROYO GRANDE HOMEFACILITY NUMBER:
405850038
ADMINISTRATOR:SHANNON MACKENZIEFACILITY TYPE:
735
ADDRESS:2119 LOPEZ DRTELEPHONE:
(805) 473-5784
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY:4CENSUS: 4DATE:
10/06/2022
UNANNOUNCEDTIME BEGAN:
10:59 AM
MET WITH:Guadalupe Ramirez, AdministratorTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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9
Staff hit resident while in care.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegation. LPA met with Administrator Guadalupe Ramirez and explained the purpose of the visit.

LPA De Leon and Quality Assurance (QA) Miguel Magana from Tri-Counties Regional Center(TCRC) conducted a joint visit to the facility on 06/22/2022 at 1:30 PM. LPA De Leon and QA Magana conducted interviews with resident and staff on 06/22/2022 at 2:00pm, 3:00pm, 3:35pm, 4:10pm, and on 06/24/2022 at 2:20pm, 2:47pm, 3:20pm, 3:40pm, 3:50pm. LPA requested, collected, and reviewed records on 06/22/2022. LPA De Leon conducted additional interviews on 06/27/2022 around 10:25am and 11:15am also on 10/06/2022 at 11:01am, 11:05am, and 11:08am.
Continued 9099
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20220616110908
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARROYO GRANDE HOME
FACILITY NUMBER: 405850038
VISIT DATE: 10/06/2022
NARRATIVE
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On the allegation: Staff hit resident while in care. LPA interviewed 11 out of 12 staff which revealed no staff have ever witnessed S8 hitting R1 at any time. On 06/10/2022, 06/12/2022 and 06/13/2022 R1 had incidents of behaviors with staff which resulted in R1’s personal rights being violated which is addressed on a case management visit. Interviews with staff revealed R1 tends to lie and steal, this is currently behaviors being addressed in R1’s behavior plan. R1 told Crisis Response that two staff hit R1 then later recanted story and said only 1 staff hit R1. Staff interviews reveal R1 and S8 seem to have a personality conflict with each other and do not feel that S8 would ever hit R1. Interviews with R2, R3, R4 revealed that S8 is a good staff and did not have any issues with S8, S8 has never hit, cussed or made fun of R2, R3, and R8 in anyway. The facility conducted an internal investigation and did not find any evidence of abuse. TCRC completed their investigation and found the allegation to be inconclusive. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2